Medical Director, Payment Integrity

Job Summary

A company is looking for a Medical Director, Payment Integrity & Utilization Management.

Key Responsibilities

• Perform detailed medical record reviews to ensure documentation aligns with medical necessity guidelines
• Review and validate clinical decision-making by vendors and providers for proper reimbursement
• Coach and train clinical decision-makers on the selection and application of medical necessity guidelines

Required Qualifications

• MD or DO with a valid, unrestricted license to practice medicine in a US State
• Board Certified in Internal Medicine, Family Medicine, or Emergency Medicine
• At least 5 years of clinical experience, including inpatient experience
• Strong experience in Payment Integrity and Utilization Management/Review
• Experience with peer review committees